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Dr Quasim Clinic

Homeopath Clinic

1,Nizamuddin west New Delhi, Delhi Delhi
1 Doctor
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Dr Quasim Clinic Homeopath Clinic 1,Nizamuddin west New Delhi, Delhi Delhi
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About

Our entire team is dedicated to providing you with the personalized, gentle care that you deserve. All our staff is dedicated to your comfort and prompt attention as well....more
Our entire team is dedicated to providing you with the personalized, gentle care that you deserve. All our staff is dedicated to your comfort and prompt attention as well.
More about Dr Quasim Clinic
Dr Quasim Clinic is known for housing experienced Homeopaths. Dr. Mohammad Quasim, a well-reputed Homeopath, practices in Delhi. Visit this medical health centre for Homeopaths recommended by 88 patients.

Timings

MON-SAT
09:00 AM - 01:00 PM 05:00 PM - 08:00 PM

Location

1,Nizamuddin west New Delhi, Delhi
New Delhi Delhi, Delhi
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Available today
09:00 AM - 01:00 PM
05:00 PM - 08:00 PM
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I have a desk job and in the last two years and my weight is gone up 72 to 80 kg. I want to loose my weight .so please help me out.

General Physician, Mumbai
I have a desk job and in the last two years and my weight is gone up 72 to 80 kg. I want to loose my weight .so pleas...
Eat healthy. And Exercise atleast 45 mins in a day. While working you could take a walk and talk to your college in a hour or two. Desk Job for a long time can lead to increase in weight.
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Mam, lumacip plus cream how long time to be used? Then its safe to the oily skin mam?

Diploma in Aesthetic Medicine, MBBS
Cosmetic Physician, Delhi
Mam, lumacip plus cream how long time to be used? Then its safe to the oily skin mam?
Hi lybrate-user, LUMACIP PLUS CREAM contains: Fluocinolone Topical (0.01% w/w, Hydroquinone Topical (4% w/w, Tretinoin Topical (0.05% w/w). Fluocinolone is a topical steroid. It is not recommended to use this on skin for long period of time without medical advice and indication. Your skin may feel better initially with its use but, it can lead to undesirable effects like flaring up of acne/other infection, unusual pigmentation and dependence. It is also not recommended to use Hydroquinone preparations for long periods of time as it can lead to side effects like hyperpigmentation /hypopigmentation too. For improving tone and texture of face, removal of dark spots and for glowing facial skin, I recommend skin lightening creams, Skin lightening capsules/tablets, Chemical peels and Microdermabrasion therapy. You will need a skin lightening cream and good sunscreen initially. I can prescribe you that. For further improvement, advanced treatments can be initiated. I would be happy to help you. Please consult me privately so that I can understand your problem in detail and help you.
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Sir please tell me that ,what is the reason behind for checking bp and sugar before surgery.

BHMS
Homeopath,
Sir please tell me that ,what is the reason behind for checking bp and sugar before surgery.
The basic reason is Raised BP will leads to increased blood loos during surgery, and raised sugar level leads to delayed wound healing after surgery and more chance for infection.
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I want to loose my weight by 5 to 7 kg and have to gain muscle what should I do? And I am also rice lover I love rice. Can I eat rice once in a week or I can also eat brown rice will that help me in reducing my weight?

BPTh/BPT, MIHS
Physiotherapist, Surat
I want to loose my weight by 5 to 7 kg and have to gain muscle what should I do?
And I am also rice lover I love rice...
You should eat limited amount of carbohydrates. Either you can eat rice or chapati. If you skip chapati or bread you can easily use rice or khichadi along with dal and vegetables. No problem in eating it. Just you need to balance and refrain from taking too much of carb. If your Basal metabolic rate is low you should take herbal extract of tribulus terrestris to reduce weight easily.
1 person found this helpful
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Respected sir/mam now my baby is 6 weeks old. Please tell me which vaccines are mandatory. And which are optional.

M.D.( Pediatrics), DCH
Pediatrician,
Respected sir/mam now my baby is 6 weeks old. Please tell me which vaccines are mandatory. And which are optional.
DPT /Hib /HepB /IPV..(some include rotateq first dose) Routinely given, you can give PCV in addition to the former. All these are to be given every month for three months. Optional is a misguided word. What it really means is, give it, if you can afford. All recommended vaccines are beneficial and are desirable but for affordability. (I use Rotarix at 10 & 14 wks instead of rotateq 6-10-14 wks. Both schedules are equally good)
1 person found this helpful
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I want gain my weight and body. My weight 42 kgs. My height 175 cms, I am use some homeopathic medicines growth my weight. 1. Alfalfa tonic, Gainsenx 1x tablets. Inlast 2 months. Not growing my weight.

BHMS
Homeopath, Mumbai
I want gain my weight and body.
My weight 42 kgs. My height 175 cms,
I am use some homeopathic medicines growth my we...
Taking medicines will not help you gain weight. Eat a protein rich but balanced & nutritious diet with salads & fruits, sleep well, take daily exercise. Once you provide your body with these, you will start seeing slow & steady results. Do not try to gain with magic potions etc. They are all fake claims which may cause more harm than good.
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Headache: Sinusitis

Diploma in Otorhinolaryngology (DLO), DNB (ENT)
ENT Specialist, Nagpur
Headache: Sinusitis

Patients having chronic nasal problems along with sinusitis often complains of headache.
They most of the time describe the headache as throbbing pain in the cheek bones, over nasal bridge and over the forehead. Which sometimes exacerbates after sudden change in position or straining.
These headaches can be confused with the migraine and hence complete examination and determining the cause of headache is very necessary.
Now what exactly leads to sinus headache. It is the sinus infection or the nasal infection or the allergy leading to congestion in the nose and the draining pathways of the sinuses causing accumulation of the fluid. This fluid in turn causes pressure and inflammation of sinuses, leading to headache.
Sometimes this fluid can get secondarily infected and then patient may experience fever, body pain etc.
Treatment for this headache is just relieve the congestion of nose and form a patent channel for the sinus fluid to drain.
This will include medications like antibiotics, antihistamines, decongestant, nasal local decongestants. Steroid sprays etc. The treatment is tailor made according to the symptoms.
Home remedies include inhaling the steam.
The bottom line is to differentiate the headache cause complete examination and sometimes investigations like ctscan or x-rays are also required and hence we should get ourselves completely evaluated and then start the medication.

Diagnostic Tests Females

DNB (Obstetrics and Gynecology), MBBS
Gynaecologist, Delhi
Diagnostic Tests Females

Diagnostic Tests Females

We provide testing for fertility by all modalities ranging from reproductive hormones to diagnostic ultrasound to ascertain the cause. It is advisable that we make you undergo these tests before your final treatment/ plan of management is started.

  • Blood tests: These include a whole array of blood investigation ranging from CBC , Urine routine microscopy, RBS, TSH, PROLACTIN, VDRL, HIV, HBSAG, HCV, AMH. And any other test depending on the history of the couple.
  • Transvaginal ultrasound: A complete ultrasound of the uterus and adnexa is done to diagnose any anatomical disorder.
  • Specific tests: In cases of recurrent implantation failure and recurrent pregnancy loss or if required other tests are also advised.
  • Diagnostic Laparoscopy and Hysteroscopy: For many, this test is an important part of a fertility evaluation. Laparoscopy takes place under general anaesthesia with small incisions made at or just below the navel and the pubic hairline. A laparoscope (a small-diameter telescope) is passed through the incision, which enables one to view the ovaries, fallopian tubes, uterus and pelvic cavity for abnormalities. We can check that the tubes are open (tubal patency) by injecting dye through the uterus and observing it spill or not through the ends of the fallopian tubes.
  • Hysteroscopy: uses another small-diameter telescope called a hysteroscope. This enables to assess the uterine cavity for abnormalities such as polyps, adhesions or fibroids.
1 person found this helpful

A Peaceful State Of Mind Is The Key To A Healthier Life

MD - Internal Medicine
General Physician,
A Peaceful State Of Mind Is The Key To A Healthier Life

Find the root of all your suffering in some negativity you are nurturing in your life. Rise above all negativity, drop down all things you are holding onto become free at this moment life is very beautiful nd we are all beautiful children of god.

4 people found this helpful

Mental Health

MBBS, MD - Psychiatry
Psychiatrist, Chennai
Mental Health

When your body is broken, you have no problem in seeking doctors help but when your mind is broken, why are you hesitant? Your mind is no holier than your body. 
Always seek doctor's help but never destroy your precious life.

2 people found this helpful

Skin Health

PG Diploma in Emergency Medicine Services (PGDEMS), Bachelor of Ayurveda, Medicine and Surgery (BAMS), MD - Alternate Medicine
Ayurveda, Ghaziabad
Skin Health

Eat 1 or 2 medium sized balls made of neem leaves everyday, it helps in curing skin itching and pimple problems.

5 people found this helpful

I am 24 years old. I don’t smoke. I don’t consume alcohol. I exercise 2 -3 days in the week at the gym for 1 hour daily. I drink tea 1-2 times a day. I have a penis that is 4.3 inches in length while erect. I had the habit of masturbation for the past 6 years. I am not married and I have not had sex with anyone. My first problem is I used to masturbate 7-10 times in a month. But for the past one year I have reduced the masturbation to 5 times a month. Sometimes I lie on my stomach with my erect penis on bed or on the spongy towel spread on the floor and rub myself on the towel and with 2-3 strokes I ejaculate. Sometimes I used to ejaculate 3 times a day. last week while bathing I soaped my penis for 5 seconds and I ejaculated immediately. I am scared that I am suffering from premature ejaculation. My second problem is I have the habit of watching porn regularly/frequently for at least 1-2 hours in 4-5 days in a week. Sometimes I used to masturbate while watching porn. I have a habit of watching Porn in my underwear or naked. For the past one year when I start getting an erection the erection rubs across my underwear’s waistband 2 or 3 times and I ejaculate. I am unable to stop watching porn. I have erotic dreams every night. Some nights when I lie on my stomach I rub my penis and I ejaculate in my sleep unconsciously. I heard that watching porn can cause erectile dysfunction. I am scared because my parents want to get me married between 25-26 years. I am scared that I will not be able to satisfy my future partner and I fear that I will suffer from erectile dysfunction caused due to watching porn. Whenever I talk or think about porn I get an erection. I have the habit of reading online sex stories daily and playing online sex games once in awhile. About 5 months I found that I ejaculate within 20-30 seconds of starting masturbation. So in order to increase my sexual stamina I started practising the start and stop technique of masturbation. I have practised it for the past five days and I have prevented ejaculation while practising i.e. I did not ejaculate at all. I did not cum during the start and stop technique. After the practice I feel a pain in my pelvic region or in my balls. So please suggest a solution to increase my penis size and sexual stamina.

B.A.M.S, Diploma in Nutrition and Health Education (DNHE, PG Diploma in Hospital Managment
Ayurveda, Delhi
I am 24 years old. I don’t smoke. I don’t consume alcohol. I exercise 2 -3 days in the week at the gym for 1 hour dai...
Dear first avoid excessive masturbation, avpid salty and spicy food, do kegel exercise, take Ayurveda medicine for that, take ashwagandha Pak and take our powerplus package.
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Hallo sir, my name sanjiv. My weight 92 kg+. How to loose my weight under 70 kg. My age 32. Please give me advise. Thank you.

Nutrition - Management of Weight & Lifestyle Related Disorders
Dietitian/Nutritionist, Delhi
Hallo sir, my name sanjiv. My weight 92 kg+. How to loose my weight under 70 kg. My age 32. Please give me advise. Th...
For weight loss. It is important to take frequent meals at regular interval of time. Empty stomach try to include 2 tsp aleovera juice+ 2 tsp amla juice in equal amount of water. In Breakfast you can museli/oats+ milk+ 1 apple /1 bowl green moong dal sprouts/1-2 besan cheela+ green chutney. In mid morning 1 cup green tea + 1 bowl fruits. Lunch 1-2 wheat bran roti+ 1bowl veg+ 1 bowl salad/1 bowl veg daliya + 1bowl curd E.T:1 cup tea+ 1bowl roasted channa/murmura Dinner: 1 bowl fruits+ 1glass skimmed milk/Grilled/roasted paneer/1-2 bowl cooked yellow moong dal+ 1bowl veg. After Dinner Take 1 cup jasmine tea.
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On corner of my upper lips there are two cuts and that patch is become so hard and it's paining. I can't open my mouth because then it will get stretch now please suggest me something because day by day it's increasing.

MBBS
General Physician, Hyderabad
What you are experiencing is cald Cheilitis meaning dry, crack lips specially in the corner of the mouth. If it is red and swollen and painful I would recommend an antibacterial cream Soframicin to be applied 3-4 times a day only to the affected area for a possible infection. Also Vitamin C deficiency can lead to this drying of lip. Limcee is Vit C chewable tablets to be taken daily 1-2 tablet a day. If the swelling, pain continues despite this you might need to take a consultation. Try and moisturize your lips as frequently as possible. Once you start this treatment you will see changes in approx 2-3 days. Hope this helps.
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What Causes Pain During Ejaculation?

BHMS, DEMS
Homeopath, Pune
What Causes Pain During Ejaculation?

Painful ejaculation, or painful orgasm, is commonly described as a pain or burning sensation that happens when a man ejaculates. He may feel pain between his anus and genitals or in his testes. He may also feel it in the urethra, the tube that semen passes through. 

A man may become so frustrated by this pain that he starts to avoid sex. His relationship with his partner may suffer as a result. Many men with painful ejaculation experience depression and anxiety. Prostatitis is only one of several causes of sexual pain in men. If you are experiencing sexual pain, which can include pain in the penis, testis, or pelvis area that occurs during sex, while ejaculating, or after sex, it could stem from a variety of causes.

The causes of sexual pain can be medical, structural, or psychological. Here’s a look at six causes of sexual pain, also known as dyspareunia.

Infections in the prostate gland, bladder, urethra, or seminal vesicles can cause intense burning or itching after ejaculations.

Some sexual pain disorders have been linked to anxiety. Pain may occur as a result of having anxiety related to sex or intimacy. Being a victim of sexual assault or abuse can manifest in sexual pain or anxiety.

There are some other common causes of sexual pain in men. While it is important to make sure you have enough lubrication, an irritation you are experiencing may actually mean you are allergic to your lubricant. That goes for other products such as spermicides and even the detergent you use to wash your clothes, as these can cause allergies and irritations that lead to sexual pain.

Physical abnormalities, such as Peyronie’s disease, a tight foreskin, other foreskin issues, scarring, or frenulum breve, can also cause sexual pain. You should see your doctor to get a complete examination to rule out any physical problems that could be causing your sexual pain.

To treat painful ejaculation, a doctor must first determine the cause of the painful orgasm.Usually this involves a thorough medical exam. Sometimes, samples of urine or semen are analyzed. Medications may help if there is inflammation of the testicles, prostate or urethra.

2 people found this helpful

Gall Bladder Stone

Fellowship in Minimal Access Surgery, FACRSI (Colo-Rectal Surgery), Ph. D - Gastrointestinal Surgery, FAIS, DNB (General Surgery), MNAMS (Membership of the National Academy) (General Surgery) , MBBS
Gastroenterologist, Bangalore
Gall Bladder Stone

Gall Bladder Stone

Courtesy -Dr.Kumar Parth (MBBS; MNAMS; FMAS; FAIS; FACRSI (Colo-Rectal Surgery) DNB; FSGE (Surgical Gastroenterology)

(Consultant Surgical Gastroenterologist), drkparth9@gmail.com, www.drparthgastro.com

Definition:   Presence of stones in the gallbladder is referred to as cholelithiasis.               

PredisposingFactors:

  • Genetics , Gender (more in women)
  • Body weight (Obesity), or rapid loss in weight , Fasting
  • Decreased motility (movement) of the gallbladder
  • Diet
  • Drugs : Cholesterol / Lipid lowering drugs , Estrogen
  • Diseases: Diabetes, blood disorder (Hemolytic anemia etc.)

Composition of Gall Bladder Stone:

Cholesterol Stone: Found in western world, causes accounted to diet rich in cholesterol.

Pigmented stone: generally found in diseases related to blood disorder

Mixed stone: Contains Calcium, magnesium, sodium phosphate ( most common type found in Asian population (India).

Symptoms :

  • (70–85%) are asymptomatic or "Silent Gall Stone"
  • Pain in right upper and central part of abdomen (may radiate to inter-scapular region) mostly after half an hour of food (seen more symptomatic after a fatty diet.)
  • post meal fullness, belching, upper abdominal discomfort
  • Jaundice (yellowing of the skin or eyes)
  • Clay colored stools or dark urine

Investigations required:

  • Blood - Liver Function test , Complete Blood Count,
  • Imaging -Ultrasound Of abdomen and if required MRI (MRCP) abdomen.
  • Complications of Gall Stone
  • Infection of gall bladder {Empyema(pus) / Mucocele of Gall bladder}
  • Perforation of gall bladder
  • Stone slipped in Common Bile Duct resulting in obstruction in the passage of bile leading to Jaundice
  • Stone from gall bladder slipped to common bile duct and entering into pancreatic duct through common channel of opening in Duodenum (small bowel) leading to Pancreatitis.

Indications for Surgery:

  • Symptomatic Gall stone with typical history of pain as mentioned above and proven with Imaging (ultrasound)
  • Asymptomatic or Silent gall stone (Found Incidentally during Ultrasound abdomen) - "DOES NOT REQUIRE SURGERY".

Asymptomatic or Silent gall stone requiring surgery in special circumstances are:

  • Pregnant lady diagnosed with gall stone during first trimester (incidental finding)
  • Any blood disorder and patient is going for any abdominal surgery for any reason.
  • Diabetes mellitus - as chances of infection are high on by ground of diabetes
  • Gall bladder polyp (a soft tissue growth in lumen of gall bladder) size > 1 cm or single stone measuring > 3 cms, as risk of Gall Bladder cancer increase by 10 fold in these cases.

Treatment: Surgery - Laparoscopic Cholecystectomy (Key Hole Surgery) is Gold standard worldwide.

  • Safe surgery, there are no side effects of removing of gall bladder as one has to weigh the complication arising from a "symptomatic" gall stone disease.
  • Can be done as a day care surgery
  • Post surgery patients are advised to refrain from fatty meal for a week so as to acclimatize the body to a diluted bile. Normal activity is allowed from day 1 of post surgery.

Parkinson s Disease

MBBS, DNB, Fellowship in Neurosurgery
Neurosurgeon, Kolkata
Parkinson s Disease

Deep brain stimulation in Parkinson’s disease

Abstract: Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson’s disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients.

Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be discussed.

Key words: deep brain stimulation (DBS); Parkinson’s disease(PD),  stereotaxis

Introduction

Parkinson's disease is a slowly progressive, neurodegenerative disease characterized by tremor, rigidity, bradykinesia and postural instability. It is the most common movement disorder in middle or late life with a prevalence of about 0.3% of the general population, rising to 1% in people over 60 years of age. Approximately 130 000 people suffer from it in the UK and it presents an increasing burden in our ageing population. Pathological findings in Parkinson's disease demonstrate greatly diminished neuromelanin pigmented neurons in the substantia nigra of the basal ganglia with associated gliosis, and Lewy bodies present in many remaining neurons.

James Parkinson, in his original 1817 Essay on The Shaking Palsy, gave an account of six patients in which he noted signs of tremor, festinating gait and flexed posture.  Nearly two centuries from Parkinson's observations, and almost four decades after Cotzias' dramatic demonstration of levodopa's efficacy, the limitations and complications of levodopa treatment for Parkinson's disease have become well documented Five years after initiation of therapy, a majority of patients develop medication related motor complications, namely levodopa induced dyskinesias (LID) and motor fluctuations. Deep brain stimulation (DBS) has been developed primarily to address these treatment related motor complications and therapeutic failures.

Pathophysiology of PD

The loss of dopaminergic neurons in the substantia nigra, the main functional characteristic of PD, affects the circuit described above and leads to the cardinal motor symptoms of PD. While the exact mechanism of this process is unknown, animal research as well as human recordings have provided functional and biochemical evidence that bradykinesia in PD results from excessive activity in the STN and the GPi. This leads to an exaggerated beta (10-30 Hz) synchronization within and between structures in the basal ganglia circuitry  that could also contribute to rigidity and akinesia.

The pathophysiology of rest tremor in PD is less clear and probably more complicated. This symptom most likely results from a dysfunction of both the striato-pallidal-thalamocortical and the cerebellodentato-thalamocortical circuits, with hyperactivity and hypersynchronization between central oscillators.

Possible mechanism of action of DBS

DBS acts through delivering an electrical current in a specific target area of the brain. This current can be modulated through modification of voltage, frequency and duration of each electrical pulse delivered. The delivered energy creates an electrical field of variable size and shape according to the parameters used for stimulation. Although initially believed to stimulate the target, thus the name of the whole process, it seems that

DBS actually excites the neuronal fibers, but inhibits the neural cells. In fact, GPi DBS decreases the GPi mean firing rate back to a normal range in animal models as well as PD patients, and high frequency DBS has a similar effect as dopamine replacement therapies, and promotes faster (about 70 Hz) nonhypersynchronous activity in the basal ganglia, correlated with clinical improvement. This might be achieved through stimulation of bypassing inhibitory pathways, synaptic inhibition, depolarizing blockade, synaptic depression, and simulation-induced disruption of pathological network activity. Overall, this leads to modifications of the firing rate and pattern of neurons in the basal ganglia, as well as local release of neurotransmitters such as glutamate and adenosine. In addition, it seems that DBS also increases blood flow and stimulates neurogenesis. Over the last few years, functional imaging, specifically functional magnetic resonance imaging (fMRI), positron emission tomography (PET) and single-photon emission computed tomography (SPECT), has been used in an attempt to clarify the mechanism of action of DBS. In fMRI, blood-oxygen-level-dependent (BOLD) signals are acquired, and oxygenated blood marks areas of neural stimulation or inhibition. On the other hand, PET and SPECT allow for imaging of multiple activity markers, such as blood flow, glucose and oxygen metabolism. While fMRI is less powerful than nuclear medicine techniques, it provides a much better spatial and temporal resolution. Because of the suspected inhibitory DBS effects in electrophysiological studies, reduced STN blood flow or glucose metabolism would have been expected on functional imaging. However, the opposite has been found to be true in an overwhelming majority of imaging studies to date. In addition, BOLD activation in the area surrounding the electrode has been reported, despite the electrode imaging artifact preventing direct observation of the STN around the electrode. This discrepancy between apparent STN inhibition in single-cell studies and activation in imaging studies might be explained by a few hypotheses. First, electrophysiological recordings identify short neuronal modulation (in the order of milliseconds) while neuroimaging methods may reflect the summed activity changes over seconds to minutes. Second, non-neuronal contributions to the change in blood flow and/or glucose metabolism cannot be excluded, and could confound the results of neuroimaging.

Finally, it is possible that PET and fMRI actually detect the increased activity in the axons, rather than in the cell bodies. Complicating matters further, some imaging studies after STN DBS have showed increased

activity in the GPi while others reported decreased activity in that nucleus. In summary, it is still unclear how exactly DBS affects the firing rate and pattern of neurons and how these changes actually modify the symptoms of Parkinson’s disease. DBS is presently more of an empirically proven treatment in search of physiological explanation.

The effect of DBS on the cardinal symptoms of PD have been established in three randomized controlled clinical trials --- 

TABLE 1

Author, year

 

No of patients

Follow up

Target

Results

Deuschl et al., 2006

156

6 months

BL STN

QOL better with DBS, motor symptom better with DBS

 

Weaver et al., 2009

255

6 months

BL STN or GPi

Dyskinesia free ON time better with DBS

 

Williams et al., 2010

366

12 months

BL STN  or GPi

QOL better with DBS

 

 

PATIENT SELECTION for DBS in PD

Patient selection is a critical first step as poorly chosen candidates may not have optimal benefits and have increased morbidity. Several factors must be considered before determining if a patient is an appropriate candidate for DBS surgery. A multidisciplinary approach involving the neurosurgeon, neurologist, and neuropsychologist is important to determine the appropriate surgical candidate. It is also important that the diagnosis of idiopathic PD be confirmed prior to proceeding with DBS surgery. Key to this assessment is evaluating the surgical candidate in both the on and off medication states with a corroborating levodopa challenge. Perhaps the best prognostic indicator of a patient’s suitability for DBS surgery is their response to levodopa.In general, a levodopa challenge following a 12-hour medication withdrawal should provide at least a 33% improvement in the motor section of the Unified Parkinson’s Disease Rating Scale (UPDRS).

                     In our institute, we follow a simple chart(below) for screening of patients for DBS in PD.

 

 

  1.  

Age<75 years

 

  •  

No

  1.  

Idiopathic PD ( No PSP/MSA/NSD etc)

 

  •  

No

  1.  

Levodopa responsive  

                      

  •  

No

  1.  

Poor/adverse response to drug          

 

  1.  Increased off period                                                              

 

  1. Disabling dyskinesia                                                              

 

 

  1. Disabling motor fluctuations                 

 

 

Yes

 

Yes

 

 

Yes

 

 

No

 

No

 

 

No

  1.  

Degree of disability(UPDRS part III score)>25

 

  •  

No

  1.  

Neuropsychology, MMSE>24

 

  •  

No

  1.  

LEVODOPA CHALLENGE RESPONSE POSITIVE                                                   

 

(30% improvement in UPDRS after 12-hours off medication)

 

  •  

No

  1.  

Advanced  co-morbidity

 

Yes

  •  
  1.  

long term anticoagulation

 

Yes

  •  
  1.  

Willing for surgery and programming

 

  •  

No

 

 

PREOPERATIVE MANAGEMENT

A full medical assessment is a necessary part of the preoperative evaluation, as advanced PD patients tend to be elderly with significant comorbidities. Major issues are---

 

Anticoagulation/antiplatelets--- The risk of discontinuing medications that affect anticoagulation and

platelet aggregation should be weighed against the potential benefits in the quality of life offered by DBS surgery. However, timely discontinuation of these latter medications is mandatory for stereotactic surgery since intracerebral hematomas are the most serious of all potential complications from DBS. Any anticlotting medications, including aspirin, ticlopidine, clopidogrel, and all nonsteroidal anti-inflammatory drugs should be discontinued at least 7 to 10 days preoperatively to ensure the return of normal blood clotting function.

Arterial hypertension can also increase the risk of intracranial bleeding during stereotactic procedures and must be controlled in the weeks prior to surgery.

A prolonged discussion on the short- and long-term effects of DBS on Parkinson’s disease should be carried out with the patient, family, and caregivers.

The night prior to DBS surgery, the antiparkinsonian medications are typically held to pronounce the Parkinson’s symptoms at the time of surgery to see the clinical effects on symptoms during surgery and the families must be counselled regarding their role in facilitating the patient.

Target selection

The two main targets considered for DBS in PD are the STN and the GPi. current tendency is to prefer targeting the STN because of a greater improvement in the OFF phase motor symptoms as well as a higher chance to decrease the medication dosage and a lower battery consumption linked to the use of lower voltage in the STN compared to the GPi DBS. GPi can be the preferred target if LID is the main complaint. GPi DBS might be preferred for patients with mild cognitive impairment and psychiatric symptoms. Because STN DBS might have a higher rate of cognitive decline and/or depression and worsening of verbal fluency in some studies.

Surgical technique

The basic components of DBS implantation surgery involve frame placement, anatomical targeting, physiological mapping, evaluation of macrostimulation thresholds for improvement in motor symptoms or induction of side effects, implantation of the DBS electrode and implantable pulse generator (IPG).

Head-frame placement

The CRW frame is the most commonly used followed by the Leksell frame. Placement of the frame is done under local anesthesia unless anxiety or uncontrollable movements necessitate the use of sedation or general anesthesia.

Leksell stereotactic frame  placed over the head of a patient showing the correct method for placement of the Leksell head-frame. The frame should be placed parallel to orbito-meatal line in order to approximate the AC-PC plane. It is attached to the patient’s head using four pins under local anesthesia.

Imaging and anatomic targeting

Computerized Tomography (CT) scans and MRI are the two main imaging modalities used for targeting when performing DBS implantations. A thin cut stereotactic CT (_2 mm slices with no gap and no gantry tilt) is obtained after frame placement and is then fused with the stereotactic MRI on a planning station (Stealth station). The advantage of fusing the CT with MRI is the ability to avoid image-distortions inherent to MR imaging adding to the stereotactic accuracy. To better define the STN, T2-weighted images (TR 2800, TE 90, flip angle 90˚, slice thickness 2.0 mm) were obtained.

The AC and the PC were marked and the centre of the AC–PC line determined. The next step is planning the entry point and trajectory. The strategy here is to avoid surface and sub-cortical vessels. After trajectory planning, the patient is placed supine on the operating table and the frame attached to the table using an adaptor. Prophylactic antibiotics are given at least 30 min prior to incision. The head is prepped and draped in a sterile fashion. Under local anesthesia, a burr-hole is placed on the calculated entry point marked on the skull. The entry point is determined by the calculated arc and ring angles. Hemostasis is achieved with bone wax and bipolar cautery.

A Medronic Stim-Loc anchoring device (Medtronic, Minneapolis, MN) burr-hole base ring is then placed on the burr-hole and secured with two screws which are used at the end of the procedure to anchor the DBS electrode.

The dura is then cauterized and opened exposing the underlying surface of the brain. The microdrive is then assembled and cannulae inserted 10 mm above the target to avoid lenticulostriate vessels found deeper. Gel- foam and fibrin glue is applied on dural hole to minimize cerebrospinal fluid (CSF) loss and air entry into the skull. Subsequently, microelectrode recording and stimulation is undertaken.

Microelectrode recording/ Mapping

Microelectrode mapping is used to precisely define the target STN and its boundaries as well as nearby critical structures. We believe microelectrode mapping is crucial in order to give one the best chance for optimal placement of the DBS lead given anatomical inaccuracies due to image distortion and intraoperative brain shifts secondary to CSF loss, and pneumocephalus that can lead to inaccuracies in defining the initial target coordinates and shifts in the target itself once the skull is opened. Microelectrode mapping is performed using platinum-iridium glass coated microelectrodes dipped in platinum black with an impedance of around 0.3–0.5 Mo. These platinum-iridium microelectrodes are capable of recording single unit activity and can also be used for micro-stimulation up to 100 mAwithout significant breakdown in their recording qualities.

As the recording electrode was advanced, entry into the STN was identified by a sudden increase in the density of cellular discharge, with the characteristic irregular pattern of discharge—spikes of different sizes, occurring at random intervals. On coming out of the STN a quiet period (background noise) was seen followed by recording from the substantia nigra if the recording was continued far enough, described as high frequency (50–60 spikes/s) discharge pattern.11 Characteristic STN recordings (visual and audio) were identified and the depth of the STN activity was noted. Identification of STN activity was only based on the visual identification. The centre of the point of best electrical activity was selected as the final target. The microelectrode was replaced with a permanent quadripolar macroelectrode (Medtronic electrode no. 3389) to target the centre of the STN electrical activity. The proximal part of this electrode consists of four nickel conductor wires insulated with a polytetrafluoroethylene jacket tubing. The distal part has four metallic noninsulated contacts of 1.5 mm spaced at 0.5 mm intervals. The diameter of the distal electrode is 1.27 mm. Based on the clinical response any of the four contacts can be used for stimulation. Macrostimulation using the DBS electrode itself is then used to determine benefits and side effects. In most cases lateral skull x rays were obtained at this point with image intensifier carefully positioned to locate the target point in the centre of the Leksell-G frame rings.

Initial programming is always refined by using intra-operative macrostimulation data and a mono-polar review to identify the thresholds of stimulation for improvement in parkinsonian motor signs as well as the thresholds for inducing side effects at the level of each contact. The four variables that are used in programming are choice of contacts (0, 1, 2 or 3 used either as the cathode or anode), frequency of stimulation (hertz), pulse-width (ms) and amplitude (voltage).

POSTOPERATIVE MANAGEMENT

In the immediate hours after surgery, it is important to keep arterial blood pressure in the normal range. In addition, the patient’s preoperative drug regimen should be restarted immediately after surgery to avoid problems with dopaminergic withdrawal. Patients should undergo postoperative CT scans and/or MRI scans to assess the electrode location and intracranial status. In addition, plain X-rays are obtained to assess the location and geometry of the leads and hardware. Parkinson’s medications may need to be adjusted depending on the patient’s status. Cognitive and behavioral changes may occur in the postoperative period, particularly in older patients. Patients can be discharged as early as 24 hours after surgery, depending on their neurological and cognitive status.

Conclusion

For the last 50 years, levodopa has been the cornerstone of PD management. However, a majority of patients develop motor fluctuations and/or LID about 5 years after the initiation of therapy. DBS of the STN or the GPI grant to patients with PD improved quality of life and decreased motor complications, and has been approved as such by the Food and Drug Administration in the US in 2002. We reviewed the experience and available literature on DBS for Parkinson’s disease over the last decade and arrive at the following understandings.

The success of DBS surgery depends on the accurate placement of the leads and meticulous programming of the stimulation. Therefore, it is best accomplished by an experienced team of neurosurgeon, neurologist, and support staff dedicated to the treatment.

Reports of surgical complication rates and long-term side-effects of DBS are very variable, so benefits and potential adverse results should not be under- or over-emphasized.

While essentially equal in improving the motor symptoms of PD, STN and GPi might have their own benefits and risks, and the choice of the target should be individualized and adapted to the patient’s situation.

Knowledge to further improve DBS treatment for Parkinson’s disease, such as a more scientific and reliable protocol on programming, strategies to minimize cognitive and psychiatric complications, and the better

long-term maintenance of the implanted device, are still lacking.

Data on the impact of DBS on non-motor symptoms affecting the quality of life of PD patients, such as pain, speech or gastro-intestinal complaints, are still scarce. Further research in these areas will help make this useful treatment even more beneficial.

Sources Of Calcium In Your Diet

M.Sc. in Dietetics and Food Service Management , Post Graduate Diploma In Computer Application, P.G.Diploma in Clinical Nutrition & Dietetics , B.Sc.Clinical Nutrition & Dietetics
Dietitian/Nutritionist, Mumbai

According to indian council of medical research (icmr) recommends:
600mg of calcium per day for your children aged from 1 to 9 years of age
The recommendation increases to 800mg per day for children ageing 10 years and above. It continues to be the same till they are adolescents (till 17 years of age). Children need more calcium than adults for growing bones.
A normal adult male and female requires 600mg/day

Calcium rda increases to 1200mg/d for pregnant and lactating mothers to meet the increased needs of the baby in the womb and to compensate for calcium secreted in the breast milk

Milk = 1 cup milk (non fat) 245g = 299mg
Yogurt = 100g = 110mg
Cheese = 100g = 83mg
Soybeans = 100g = 277mg
Tofu = 100 = 350mg
Almonds = 100g = 264mg
Sesame seeds = 100g = 975mg

Some important facts about calcium:
Vitamin D is essential for adequate calcium absorption

There are some anti-nutritional factors in certain foods which decrease the absorption of calcium. These are oxalates present in green leafy vegetables, horse gram dal, gingelly seeds etc; and phytates present in whole cereals. They bind calcium and make it unavailable for absorption.

When the dietary intake of calcium is low, the release of calcium from bones increases in order to maintain blood levels. If this process continues for long, bones will ultimately become so weak that they may break.

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